Basic Information
| Provider Information | |||||||||
| NPI: | 1811147697 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RANDELSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5932 COUTON DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2515335480 | ||||||||
| FaxNumber: | 2519372048 | ||||||||
| Practice Location | |||||||||
| Address1: | 5932 COUTON DR | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366933002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2515335480 | ||||||||
| FaxNumber: | 2519372048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.